ABSITE:
THE NITTY, GRITTY STUFF
PART 2
KRUKENBERG TUMOR?
 Colon
or stomach cancer metastasis to
ovary
 Histology?

Signet rings
NAME THE GENETIC MUTATION
 FAP

APC gene
 Medullary

thyroid cancer
RET proto-oncogene
BOWEN’S DISEASE
 Intra-epithelial
squamous cell carcinoma
of the anus
 Treatment:

Wide local excision
ESOPHAGEAL MANOMETRY
 Normal

15-25mmHg
 Normal

LES tone?
4cm
length?
ESOPHAGEAL MANOMETRY
 No
peritalsis, high LES pressure, fails to
relax
 Next

step in management?
Barium swallow
 Dilated esophagus that ends in a bird’s beak
 Management?

Heller myotomy
WHAT IS THIS DISEASE PROCESS
 Achalasia

Decreased ganglion cells in Auerbach’s plexus
DURING ESOPHAGECTOMY …
 Decide
to use the stomach to replace the
esophagus…
 What

is the blood supply to the stomach
Right gastroepiploic artery
HEAD AND NECK
 #1


benign tumor of the parotid gland
Pleomorphic adenoma
Treatment?
 Superficial parotidectomy (spare facial
nerve)
BEEP, BEEP, BEEP … 6-5566
(GROAN)
 Patient
who has RUQ tenderness, febrile
and hypotensive
 On
exam… jaundice, solmnolent
 Next
step in management?
Resuscitation, abx, emergent drainage of CBD
 ERCP with sphincterotomy
 GI unavailable  common bile duct
exploration

NERVE INJURY
A
17yo is stabbed in the axilla. He is
noted to have loss of function of the ulnar
nerve. If nonoperative therapy is used for
treatment of this nerve injury, at what
rate is the nerve expected to regenerate?





A) 1mm/wk
B) 1mm/mo
C) 1mm/day
D) 10mm/mo
E) 1cm/wk
HEMATOMAS
 Epidural



hematoma
Characteristics on CT?
 Lens shape
History
 Lucid interval
Arterial or venous injury
 Arterial – middle meningeal
 Tempoparietal skull fracture
HEMATOMAS
 Subdural


hematoma
Characteristics on CT?
 Crescent shape, conforms to brain
Arterial or venous injury
 venous
CONN’S SYNDROME
 Characteristics?

HTN, low K, high Na
 80%
adenoma (surgical resection)
 20% bilateral hyperplasia (medical
treatment)
 Hyperaldosteronism
CLINIC ANYONE?
 Patient

complaining of an “ugly” scar
Exam: raised and extends outside of wound
margin
 Keloid

Difference between keloid & hypertrophic
scar?
 Hypertrophic scar  does not extend beyond
margins
 Treatment?

Steroid injection
WOUND HEALING
 Patient
is now 5 days post-op….and needs
to go back to the OR for retained sponge
 Wound
healing… quicker, slower, or no
change

Quicker
 All the cells are in place already

Macrophages, fibroblasts
BEEP, BEEP, BEEP…..6-5804
 Patient
 Next
s/p open chole with temp 400
step in management?
Look at wound….drainage, color, cx to the lab
 Gram stain = G+ rods, no WBCs

 What

are you worried about?
Clostridium
 Treatment:


Debridement
Abx: PCN
THE CELL CYCLE
 The


G1
G0, P53
 The

most RNA synthesis
G1
 The

most variable period
most radioresistent
S

Repair enzymes
RESPIRATORY QUOTIENT
 Fat

0.7
 Carbs

1.0
 Mixed

fuel
0.85
 Brain

RQ = 1
GLUTAMINE
 Which
is not true?
A) Essential for small bowel mucosa
 B) Essential for replicating cells
(macrophages)
 C) Source for purines and pyrimidines
 D) Is an essential amino acid

NUTRITION
 70
y/o patient with obstructed esophageal
cancer was admitted with severe
malnutrition. TPN was started. 48 hr
later, patient developed respiratory
distress and was confused. CT chest: no
pulmonary embolism. The most likely
nutritional abnormality is




A) hypokalemia
B) hyperglycemia
C) hypophosphotemia
D) hyponatremia
NUTRITION
 35
y/o multiple trauma patient (not septic)
is intubated in the SICU. Which of the
following is most helpful to decrease
protein catabolism in the first 72hr




A) adequate analgesia & sedation
B) early use of TPN
C) daily administration of 120gm glucose
D) early enteral nutrition
WHY 120GM OF GLUCOSE
 D5=


50gm/L
Run IVF @ 100cc/h
120gm glucose
 Needed
 Still
for the brain
in catabolic state (low RQ)
 Rising RQ  signs of recovery, anabolic
state, start TPN or enteral nutrition
CODE 99
 During
CPR for cardiac arrest, which of
the following is the earliest indication of a
better outcome
A) rising DBP
 B) rising SBP
 C) return of sinus rhythm
 D) return of end tidal CO2
 E) decrease in base deficit

 Starting
a lap chole, a 35 y/o patient
became severely hypotensive, lost end
tidal CO2, airway pressure is normal.
The most appropriate next step is




A) insertion of chest tube
B) increase minute ventilatin
C) trendelenburg position
D) fiberoptic bronchoscopy
SVO2
 All
are true, except
A) is increased by paralysis and decreased by
shivering
 B) the lowest value is at the coronary sinus
 C) is decreased in VSD
 D) can be directly measured from a swan ganz
catheter

IABP
 Contraindications
to an intra-aortic
balloon pump
Aortic regurgitation
 Severe peripheral vascular disease
 Aortic aneurysm (presence of synthetic
thoracic aortic graft)

IABP
 Mechanism
of action
Increases coronary perfusion by increasing
diastolic blood flow
 Decreases afterload
 Decreases myocardial O2 consumption



When does it inflate?
When does it deflate?
HARD SIGNS OF ARTERIAL INJURY IN
TRAUMA
 Active
hemorrhage
 Pulsatile hematoma
 Lack of distal pulses
 Thrill or bruit
 Acute ischemia
 Go
to the OR
SOFT SIGNS OF ARTERIAL INJURY
 Proximity
 History
of hemorrhage
 Minor hemorrhage
 Small hematoma
 Associated nerve injury
 Further
evaluation needed
KTI LEVEL 1 … ETA 30 MINUTES
7
yo is involved in a bicycle accident &
brought to the ER with LUQ pain. CT
reveals a spleen with multiple fractures &
hemoperitoneum. What are the
indications for splenectomy




A) persistent vomiting & anorexia
B) increasing hemoperitoneum on CT
C) transfusions exceeding 50% of the blood
volume
D) 2 episodes of hypotension responding to
transfusions
A
known alcoholic with a history of
several hospitalizations for acute
pancreatitis presents with persistent
hematemesis. EGD reveals gastric
varices. Appropriate treatment is




A) sengstaken-blakemore tube
B) TIPs
C) portocaval decompression operation
D) splenectomy
 Splenectomy
is indicated for ITP in which
of the following conditions
A) subarachnoid hemorrhage
 B) children under 15 yo
 C) following a good response to prednisone
 D) after a non-response to IgG

A
40 yo alcoholic patient underwent an
exploratory operation for acute abdomen
& at surgery was found to have leaking
pseudocst in the tail of the pancreas. A
tube drainage was performed. The
patient is now 2 weeks post-op & has a
persistent pancreatic fistula of 200cc/day.
Medical management has failed to reduce
the drainage. The procedure of choice




A) drainage of the fistulous tract into jejunum
B) resection of the tail of the pancreas
C) ERCP followed by pancreaticojejunostomy
D) continued medical management
 Which
of the following statements
regarding the anatomy of the liver is
correct




A) the falciform ligament provides the
landmark between the right & left lobes
B) sub-segments of the liver are readily
identified by external landmarks
C) the vena cava serves as the posterior
landmark for the division between the right &
lefts lobes
D) the gallbladder is the landmark between
the medial & lateral segments of the right lobe
of the liver
 The
anterior scalene muscle
A) separates the brachial plexus & the
brachial artery
 B) is posterior to the subclavian vein
 C) lies anterior to the subclavian vein
 D) inserts on the clavicle

 In
advanced peripheral vascular disease,
findings of dry gangrene are noted at the
mid calf level. Arterial occlusion is most
likely at which level




A) popliteal artery
B) common femoral artery
C) superficial femoral artery
D) external iliac artery
 Postpartum
ovarian vein
thrombophlebitis
A) is resistant to treatment with heparin
 B) may be clinically confused with appendicitis
 C) requires antibiotic treatment & surgical
resection
 D) requires laparoscopy or laparotomy for
definitive diagnosis

 An
aldosterone tumor is suspected in a
hypertensive patient. A saline load
challenge will exhibit
A) elevated urinary K levels
 B) low urinary aldosterone levels
 C) hyperkalemia
 D) metabolic acidosis

 An
elderly female presents with extreme
somnolence, hypoactive reflexes & a
distended abdomen. The serum calcium is
14mg/dl. Appropriate treatment is




A) immediate parathyroidectomy
B) mithramycin
C) saline & lasix
D) cortisone
 Detection
of the BRCA-1 gene in a woman
with breast cancer places her at highest
risk for
A) an ovarian cancer
 B) a 2nd breast cancer
 C) uterine cancer
 D) colon cancer

 The
histological breast lesion associated
with the highest risk of developing breast
cancer is
A) fibrocystic disease
 B) sclerosing adenosis
 C) atypical hyperplasia
 D) intraductal papilloma

 The
optimal rate of glucose
administration for a patient on TPN
A) 1-2gm/kg/hr
 B) 5-6gm/kg/hr
 C) 8-10gm/kg/hr
 D) 15-20gm/kghr

 The
predominate cause of weight loss in
cancer patients is
A) inadequate nutritional weight loss
 B) GI obstruction
 C) incomplete metabolism of glucose
 D) cachexon-induced anorexia

 Following
resection of the terminal small
bowel for crohn’s disease, which of the
vitamins will be deficient
A) thiamine
 B) vitamin c
 C) riboflavin
 D) vitamin e

 The
pre-transplant crossmatch involves
A) recipient lymphocytes & donor plasma
 B) recipient plasma & donor lympocytes
 C) recipient macrophages & donor globulins
 D) recipient globulins & donor macrophages

 Adherence
of leukocytes to the
endothelium is due to
A) integrins
 B) P-selectin
 C) L-selectin
 D) E-selectin

 The
fluoroquinolones
A) are primarily effective in gram +
bacteremia
 B) have low concentrations in bile
 C) chronic liver disease dramatically affects
pharmacokinetics
 D) are greater than 50% excreted unchanged
in the urine

 The
source of free oxygen radicals in
reperfusion injury is
A) superoxide
 B) hydrogen peroxide
 C) hydroxy radicals
 D) xanthine oxidase

 Marfan’s
syndrome is associated with all
of the following except
A) aortic valve insufficiencys
 B) incomplete collagen formation
 C) abnormal bleeding
 D) decreased bone mass

 The
changes associated with a mucous
producing villous adenoma of the sigmoid
A) metabolic acidosis
 B) hypokalemia
 C) urine pH 8.0
 D) serum HCO3 of 15

 Complications
of hypothermia include
A) convulsion
 B) tachycardia
 C) diuresis
 D) hypercoagulation

 The
nerve most commonly injured in a
laparoscopic preperitoneal inguinal hernia
repair is
A) obturator
 B) genitofemoral
 C) ilioinguinal
 D) iliohypogastric

A
30yo female attempts suicide with the
ingestion of lye. Examination of the mouth
& pharynx demonstrates erythema.
Appropriate management is




A) IVF, antibiotics & observations
B) esophagoscopy to level of the 1st burn
C) esophagoscopy to include the stomach
D) laparotomy, gastrostomy & TPN
A
68yo presents with signs of sepsis,
substernal chest pain & air crepitus in the
left neck. These symptoms & signs
developed 16hr ago after forceful vomiting
of a heavy meal. Treatment should
include




A) chest tube, IVF & antibiotics
B) left thoracotomy & repair
C) right thoracotomy & repair
D) laparotomy & repair
 12hr
following esophagoscopy & biopsy of
an obstructing esophageal cancer, the
patient presents with fever & substernal
chest pain. Esophagogram reveals
perforation of the distal esophagus.
Appropriate treatment is




A) esophageal tube suction, IVF & antibiotics
B) chest tube, esophageal suction, IVF &
antibiotics
C) closure of the perforation, chest tube, IVF &
antibiotics
D) esophagectomy & esophagogastrostomy
A
patient is placed on IVF & NPO
following an uneventful laparotomy. 12hr
later the patient develops palor, sweating,
hypotension & abdominal pain. On exam
the upper abdomen is distended &
tympanic with a succussion splash.
Appropriate action is




A) increase IVF & transfuse pRBCs
B) return to the OR
C) insert NGT
D) provide ventilatory support
 Splenectomy
may be useful in the
management of
A) hairy cell leukemia
 B) malaria
 C) chromic myelogenous leukemia
 D) sickle cell disease

A
pulmonary function that would prohibit
a successful pneumonectomy is
A) FEV1 of 1000
 B) pCO2 47
 C) ability to climb 2 flights of stairs
 D) previous MI

 The
most common complication of a
popliteal aneurysm is
A) thrombosis
 B) embolization
 C) rupture
 D) neurolysis

 The
IMV
A) drains the distal rectum
 B) passes lateral to the ligament of treitz
 C) joins the portal vein
 D) is medial to the aorta

 The
right renal artery passes
A) anterior to the vena cava
 B) anterior to the renal vein
 C) anterior to the renal pelvis
 D) anterior to the IMV

 The
muscle anterior to the femoral artery
in the Hunter’s canal is
A) adductor minimus
 B) adductor magnus
 C) quadriceps femoris
 D) vastus medialis

 Which
of the following group of drugs will
provide effective treatment for
hypertrophic subaortic stenosis
A) inotropes
 B) Ca channel blockers
 C) ACE inhibitors
 D) loop diuretics

 The
etiology of myasthenia gravis is
A) insufficient Ach
 B) motor nerve axonal degeneration
 C) decreased number of Ach receptors
 D) overproduction of Ach esterase

 The
earliest sign of uncal herniation is
A) unilateral pupil dilatation
 B) deep coma
 C) contralateral decerebrate posturing
 D) bilateral decerebrate posturing

A
30yo female with a history of
dysmenorrhea & dyspareunia is found to
have a tender 3cm smooth submucosal
rectal mass. Appropriate treatment is




A) danazol
B) Flagyl
C) LAR
D) TAH-SBO
 Treatment
of a malignant melanoma 2mm
in depth is




A) excision with 1cm margins
B) excision with 2cm margins & sentinel node
biopsy
C) excision with 4cm margins & prophylatic
node dissection
D) excision with 1cm margins & interferon a
 Malignant
pheochromocytoma is clearly
identified by which of the following
A) capsular invasion
 B) venous invasion
 C) invasion of adjacent structures
 D) histological examination

 The
only certain sign of parathyroid
malignancy is
A) histologic features
 B) renal disease
 C) bone disease
 D) recurrence after resection

 The
location of a lost upper parathyroid is
likely to be found
A) intrathyroid
 B) with the thymus
 C) adjacent to the inferior thyroid artery
 D) in the tracheoesophageal groove

 Proper
treatment for a 3cm papillary
thyroid cancer with tumor involving 4
lymph nodes is




A) ipsilateral lobectomy with resection of
involved lymph nodes
B) total thyroidectomy
C) total ipsilateral lobectomy, near total
lobectomy on the contralateral side, & resect
involved lymph nodes
D) total thyroidectomy, central compartment
node dissection & modified radical neck
dissection
 Appropriate
treatment for family
members (without tumor) having a
heterozygous RET proto-oncogene is
A) observation
 B) total parathyroidectomy
 C) total thyroidectomy
 D) bilateral adrenalectomy

 Failure
to identify gamma radiation or
blue dye in a sentinel node biopsy
procedure is due to
A) no evidence of metastatic disease
 B) incorrect FNA diagnosis of cancer
 C) failure of dye & radiolabeled colloid to
migrate
 D) absence of axillary lymph nodes

 The
appropriate ultrasound probe for
examination of a breast mass is
A) 1.5-2.5 mHz
 B) 3-3.5 mHz
 C) 5-5.5 mHz
 D) 7.5-10 mHz

 Which
of the following is the mediator
that leads to relaxation of the sphincter of
Oddi, is partially mediated by cholinergic
stimuli, & has a diminished effect
following vagotomy





A) somatostatin
B) glucagon
C) cholecystokinin
D) gastrin
E) secretin